FBT Outreach, Patient Navigation Boost CRC Screening

Fran Lowry

October 18, 2018

Fecal blood test (FBT) outreach and patient navigation are the best strategies for increasing rates of screening for colorectal cancer (CRC) in the United States, concludes a new review of all relevant randomized clinical trials conducted since 1996.

The review was published online October 15 in JAMA Internal Medicine.

The researchers, led by Michael K. Dougherty, MD, University of North Carolina at Chapel Hill, used random-effects meta-analysis to obtain pooled risk ratios (RRs) and risk differences (RDs) for completion of any screening test in 73 randomized clinical trials. The trials included 366,766 patients.

Compared to usual care, FBT outreach increased completion of any CRC screening test more than twofold (RR, 2.26).

Next was patient navigation, through which trained individuals guided patients to appropriate screening. Compared to usual care, the RR for patient navigation was 2.01.

Other interventions that improved CRC screening completion rates included the following:

  • Patient education (RR, 1.20)

  • Patient reminders (RR, 1.20)

  • Clinician reminders (RD, 13%)

Combining interventions, for example, adding clinician interventions or navigation to FBT outreach, was associated with greater increases than single component interventions (RR, 1.18).

The study also found that repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09).

However, patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21).

The authors conclude that FBT outreach should be incorporated into population-based screening programs.

They also call for more research on interventions that will "increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation."

In an accompanying commentary, Beverly B. Green, MD, MPH, from Kaiser Permanente Washington Health Research Institute, Seattle, writes that this analysis "can and should inform decision makers. We can now safely say that, in general, no more studies are needed to demonstrate that outreach with FBT and patient navigation increase CRC screening."

Green suggests that the thing to do now is to research other areas of CRC control, including barriers to screening.

One such barrier is cost.

For example, the Affordable Care Act mandated that insurance plans cover CRC screening tests with no out-of-pocket costs. However, if screening leads to the removal of a polyp or a diagnosis of cancer, that screening test becomes a diagnostic procedure, for which screening-test insurance coverage does not apply. Patients are on the hook to pay thousands of dollars.

"We need research in other areas of the CRC control continuum, including how best to implement evidence-based strategies and adaptations needed for different settings and populations, how to ensure follow-up after a positive CRC test result, what interventions increase adherence to ongoing CRC screening, and ultimately, what association CRC control programs have with CRC incidence, mortality, and health equity," Green writes.

Major funding for the study was provided by the University of North Carolina Lineberger Comprehensive Cancer Center through its University Cancer Research Fund. Dr Daugherty and Dr Green report no relevant financial relationships.

JAMA Intern Med. Published online October 15, 2018. Abstract, Commentary

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